Front Matter

Edited by

Teddy G. Goetz, M.D., M.S.

Alex S. Keuroghlian, M.D., M.P.H.

The Gender Minority Stress and Resilience Framework 15

Adaptation, Cultural Resilience, and Indigenous Identities 71

Being Neurodiverse and Gender Diverse 109

Mental Health Concerns for TNG Individuals 139

Recognizing and Managing Transphobic Countertransference in Psychotherapy 171

Sex and Gender Taxonomies and Data Collection, Storage, and Use 309

Ph.D. Student, Ontario Institute for Studies in Education, University of Toronto, Toronto, Ontario, Canada; Junior Fellow, Center for Applied Transgender Studies, Chicago, Illinois; Transgender Professional Association for Transgender Health, Toronto, Ontario, Canada

Research Scientist, Whitman-Walker Institute, Washington, DC

Child, Adolescent, and General Psychiatrist; Adjunct Voluntary Professor, Keck School of Medicine, Los Angeles, California; Psychiatrist, Reswell-Pasadena, Pasadena, California; Co-Director, Refugee Health Alliance, Tijuana, Mexico

Independent Practice, Connecticut River Valley, Massachusetts

Resident Physician, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania

Operations Coordinator, The Fenway Institute, Boston, Massachusetts

Research Fellow, The Bartlett School of Sustainable Construction, University College London, London, United Kingdom

Programmer/Analyst, The Fenway Institute, Boston, Massachusetts

Founding Director, LGBTQ+ Advocacy Clinic, Harvard Law School, Cambridge, Massachusetts

Doctoral Student, Department of Counseling and Educational Development, The University of North Carolina at Greensboro, Greensboro, North Carolina; Licensed Clinical Mental Health Counselor Associate, Banyan Tree Counseling and Wellness, Winston-Salem, North Carolina

Trans Health Program Manager, Fenway Health, Boston, Massachusetts

Master’s Student, School of Public Health and Social Policy, University of Victoria, Victoria, British Columbia, Canada

Assistant Clinical Professor of Counseling, Seattle University, Seattle, Washington

Project Coordinator, Spatial Epidemiology Lab, Columbia University Mailman School of Public Health, New York, New York

Chief Executive Officer, Transhealth; Assistant Professor, University of Virginia School of Medicine and Nursing, Charlottesville, Virginia; Assistant Professor, Columbia University, New York, New York

Deputy Director of Education and Training Programs, The Fenway Institute, Boston, Massachusetts

Ph.D. Candidate, Institute of Public Health Genetics, University of Washington, Seattle, Washington

Clinical Assistant Professor, Department of Psychiatry, University of Pittsburgh; Medical Director, UPMCLGBTQ+ Health, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Chief Medical Officer, The Jed Foundation; Assistant Professor of Psychiatry, Columbia University Medical Center, New York, New York

Assistant Professor of Psychiatry and Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

Director of Data Analytics, The Fenway Institute, Boston, Massachusetts

Consultation-Liaison Psychiatry Fellow, Mayo Clinic, Rochester, Minnesota

Yerby Post-Doctoral Fellow, Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts

Equal Justice Works Fellow, Transgender Legal Defense and Education Fund, Somerville, Massachusetts

Resident Physician, Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania

Associate Vice President for Informatics and Data Services, The Fenway Institute, Boston, Massachusetts

Assistant Professor, Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania

Assistant Professor, School of Social Work and Criminal Justice, University of Washington at Tacoma, Tacoma, Washington

Co-Director, Child Cognitive-Behavioral Therapy Program, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts

Doctoral Student, Graduate School of Social Work, University of Denver, Denver, Colorado

Clinical Associate Professor of Psychiatry and the Behavioral Sciences, Pediatrics, and Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, California

Assistant Clinical Professor of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; Co-Founder/Co-Director, Refugee Health Alliance, Tijuana, Mexico

Psychiatrist, Crouse Addiction Treatment Services, Crouse, New York

Clinical Associate Professor of Psychiatry, University of Pennsylvania; Director of Behavioral Health Emergency Services, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania

Associate Professor, School of Social Work and Department of Women’s and Gender Studies, University of Michigan, Ann Arbor, Michigan

Associate Chief, Public and Community Psychiatry, Department of Psychiatry, Massachusetts General Hospital; Michele and Howard J. Kessler Chair and Director, Division of Public and Community Psychiatry, Massachusetts General Hospital; Associate Professor of Psychiatry, Harvard Medical School; Director, Division of Education and Training, The Fenway Institute, Boston, Massachusetts

Psychiatrist/Clinical Instructor, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts

Director, LGBTQIA+ Aging Project; The Fenway Institute, Boston, Massachusetts

Postdoctoral Fellow, Yale Center for Medical Informatics, New Haven, Connecticut; Senior Fellow, Center for Applied Transgender Studies (CATS), Chicago, Illinois

Psychiatry Specialist, Sylmar, California

Assistant Professor, Counseling and Counseling Psychology, Arizona State University, Phoenix, Arizona

Transgender Outreach and Engagement Specialist, LGBTQIA+ Aging Project; Store Manager, The Fenway Institute, Boston, Massachusetts

Medical Director, Outpatient Behavioral Health, Einstein Medical Center; Clinical Assistant Professor of Psychiatry and Human Behavior, Thomas Jefferson University, Philadelphia, Pennsylvania

Postdoctoral Fellow in Psychology, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts

Assistant Professor, Department of Psychology, Michigan State University, East Lansing, Michigan

Research Assistant, School of Health Information Science, University of Victoria, British Columbia, Canada

Director, Transgender Research, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital; Harvard Medical School; The Fenway Institute; Department of Epidemiology, Harvard T.H. Chan School of Public Health

Assistant Professor, Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington; Researcher, Department of Social and Behavioral Sciences, Yale University School of Public Health, New Haven, Connecticut

Professor, Department of Psychiatry, Columbia University, New York, New York

Senior Program Development Lead, Equip Health, Carlsbad, California

Postdoctoral Scholar, Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota

Postdoctoral Fellow, Cold Spring Harbor Laboratory Postdoctoral Fellow, Cold Spring Harbor, New York

Postdoctoral Fellow, Einstein Lab of Cognitive Neurosciences, Gender and Health, Department of Psychology, University of Toronto, Toronto, Ontario, Canada; Junior Fellow, Center for Applied Transgender Studies, Chicago, Illinois

Family Medicine Specialist, Syracuse, New York

Assistant Professor, Women’s and Gender Studies, Athabasca University, Athabasca, Alberta, Canada

Ph.D. Student, Division of Psychiatry, Institute of Mental Health, Faculty of Brain Sciences, University College London, London, United Kingdom

Welcome to Gender-Affirming Psychiatric Care! This volume represents the first textbook dedicated to providing affirming, intersectional, and evidence-informed psychiatric care for transgender, non-binary, and/or gender-expansive (TNG) people.

For millennia, outside of European colonial influences, gender diversity has flourished to varying degrees among hundreds of Indigenous communities around the world. In comparison, the field of psychiatry is but a hundred-year blip. Your reading these words was far from inevitable. We launch this handbook into a specific, complicated cultural moment. Just 50 years ago, the American Psychiatric Association stopped classifying homosexuality as a psychiatric diagnosis. In 2013, DSM-5 (American Psychiatric Association 2013) replaced gender identity disorder (pathologizing gender) with gender dysphoria (pathologizing distress from gender-body incongruence). The decade since has brought unprecedented visibility and recognition of gender diversity, chased by ongoing political backlash against people’s autonomy over identification, embodiment, expression, reproduction, and family making. That backlash targets those who have been systematically marginalized and erased on the basis of race, class, ability, religion, immigration status, body size, and more.

Where will this collision leave us? As medical and mental health professionals? As TNG people? These identity categories are far from mutually exclusive: this textbook is a proud, intentional product of voices from this nexus. In her seminal article “Situated Knowledges,” science, technology, and society studies scholar Donna Haraway argued that scientific neutrality is a fallacy, as training and personal perspective influence the questions we think to ask and accordingly shape the answers that we find (Haraway 1988). Who conducts work matters; voices shape the stories that get told. As editors, we approached every stage of this project with expertise gleaned from both professional and lived experiences. We are both TNG psychiatrists, and carry many other identities (individually or together) that directly informed this work, such as queer, chronically ill, neurodivergent, Jewish, Middle Eastern, immigrant, child of civil war refugees, and descendent of genocide survivors. We are also both obscenely privileged in many respects, for example as English-speaking American physicians who had access to rarefied medical education and training at some of the world’s best-resourced academic institutions.

We did our best to choose authors while prioritizing lived experience, diversity of perspectives, and community impact of prior work over academic titles. The following 26 chapters were written by a total of 56 authors, 50 of whom are TNG (89%). Each chapter has at least one TNG author, and the authorship of chapters focusing on specific intersectional identities is composed of community voices. Contributors collaborated to offer interdisciplinary perspectives from the fields of psychiatry, psychology, social work, nursing, pharmacy, epidemiology, public health, law, sociology, gender studies, business, community activism, and more. To our knowledge, this is the first book on TNG health produced by field experts who bring lived experience to their clinical and scholarly work. We explicitly name this process to demonstrate that such a representation is more than possible: it fuels the authenticity, relevance, and quality of our work. We hope that future efforts similarly lead with community member expertise to drive conversations about health equity.

During the editing process, we have struggled with terminology, which is as dynamic as gender itself. Our field’s lexicon is constantly evolving and will continue to do so after the publication of this textbook. We made decisions here to the best of our ability, acknowledging the inherent imperfection of our linguistic framework. The following list represents choices made at the time of sending to press, with input from many fellow interdisciplinary TNG scholars and community members. We sought to use consistent definitions where possible, with some exceptions when intentional conceptual distinctions were necessary. Below, we briefly explain some such choices:

In this undertaking, it was imperative to consider our positionality as psychiatrists, trained and working within a field built on the work (and assumptions) of European, white, cisgender men, including their colonial, Anglocentric, cisheteropatriarchal worldview and pathologization of experiences that did not fit their own “norm.” We acknowledge that such biases remain explicitly and implicitly within psychiatric training and practice and, despite our best efforts, undoubtedly have influenced this handbook. We have attempted to shift the norm/reference value away from the mythical man-woman binary and instead center the widespread historical legacy of gender diversity, with particular attention to (and authorship from) Two-Spirit and other Indigenous identities and roles that colonizers attempted to destroy. Our effort was constrained by space and remains just a start; we encourage you to continue reading work from Two-Spirit and all TNG Indigenous scholars, activists, and community members, to continue learning from the ancestral heritage of gender diversity.

The textbook begins with a discussion of epidemiology, minority stress and resilience, the neuroscience of gender, and psychopharmacological considerations for prescribing with TNG people. Chapters 5–10 are dedicated to providing intersectional gender-affirming care for and meeting the access needs of a series of specific, multiply marginalized communities: those who are Two-Spirit, Black, Asian American, and Pacific Islander; those who are neurodivergent and disabled; and migrants, refugees, and unhoused people. Chapters 11 and 12 help readers develop clinical tools to provide trauma-informed care and mitigate their own transphobic countertransference across settings. Chapters 13 and 14 focus on working with TNG people, and their families, in a developmentally appropriate manner across the life span, from children and adolescents to older adults. The chapters that follow are organized by psychiatric clinical specialty area and pertain to affirming gender identity in the context of eating disorders, substance use disorders, pregnancy, and serious mental illness. We then consider the specific care needs of populations who carry the compounding traumas of incarceration and gender identity conversion efforts, followed by guidance for providing an assessment in support of gender-affirming surgery. The final chapters explore systems-level change, including collecting gender identity information in electronic health records, building gender-affirming clinical environments, mental health law and policy considerations, and a case study of how TNG leaders can reimagine and transform delivery of gender-affirming mental health care. These chapters are not mutually exclusive in their content and considerations. We have done our best to remove redundancy and cross-reference pertinent chapters where beneficial.

We hope that this handbook, although necessarily not comprehensive, can serve as a guide for broadening readers’ understanding of the richness and complexity of gender-affirming mental health care. We were limited by spatial constraints: there could have been dozens more chapters, and our exclusion of any topic is not a statement about its lack of importance. We hope this is just a starting point for more continued discourse, and in future handbooks we look forward to reading and learning about all of the compelling topics not highlighted here. We hope these chapters leave you with as many questions as answers. We hope they inspire you to create space for, listen to, and actionably affirm TNG people with lived experience in your own spheres. There is so much work to be done. Thank you for joining us.

Teddy G. Goetz, M.D., M.S.

Alex S. Keuroghlian, M.D., M.P.H.

Content Warning: This book contains discussions of trauma; gender identity conversion efforts; prejudice toward TNG people (ageism, cisgenderism, misogyny, misogynoir, racism, sexism, transphobia, xenophobia) and those with autism, disabilities, eating disorders, mental illness, neurodivergence, and substance use disorders; historical negation and abuse; and pathologization of gender expression.